Dr. Best, again, thank you for joining us. One of the themes that I've heard from folks elsewhere, and one of the things that I think we should emphasize is that many of us who have these cardio obstetrics teams are often based in major tertiary referral medical centers, whereas a lot of these patients, that's not necessarily where they're presenting, they're presenting at outside facilities. And so I think the themes of, you know, treat the mother, you know, prioritize the maternal care, you know, do you have any insight or thoughts on how to sort of perhaps get other cardiologists to sort of overcome their fears a little bit and, you know, progress towards really treating the whole patient and not being as skittish about treating pregnant women? Yeah, every time a woman is pregnant, and there's any consideration of going to the catheterization laboratory, or they've just been pregnant, or it's a SCAD patient, there's more concern than you would see otherwise with any other patient going to catheterization laboratory. And some of it is really you have to remember that the risks of not doing something for the mother is putting risk to both the mother and the baby. And so that you really have to continue to remember to aggressively treat the mother, because risks to her are risks to the baby. And so that a small radiation risk is just a small risk that's more theoretical than the risk of missing a disease that needs to be treated in the catheterization laboratory. You know, some of the team approaches can have very different challenges depending on the institution. Our institution actually, because of historically our hospital is a Catholic hospital, and we have another hospital, you know, a mile down the road, where most of our OB patients are taken care of because it's not a Catholic hospital. And all of our cardiology is over at the Catholic hospital. There can be some interesting shifts that you have to do to work through some of the arenas to get all the right people on board. And sometimes it's really, it's working with the circumstances of what you need for each case, and working at what's best for each patient, and bringing all the right people in, and having that list of the people who will know the most about the cardio OB patients, and, you know, who's on your short list to call for each issue is really very important. Yeah, absolutely. Yeah, it's an interesting point about inter-facility dynamics, of an already complex patient situation, and that's another element. Right, it's like socioeconomic factors at certain hospitals, it's, you know, how much pre-pregnancy care someone gets, how much, you know, someone's going to go see their OB during pregnancy, all of those factor into what your population is going to look at, look like, and when you're going to catch the patients, and what their risks are with all of those things. Absolutely, yeah, those are really fantastic points. I'd actually like to also hit one other thing that Dr. Volz had on her slides about how a third of the cath labs actually reject women being pregnant in the cath lab working, and as a side note for the practitioners, that's actually illegal in the United States, and so that for all trainees and anyone else on the webinar, you need to know your rights on that, and so please don't let that deter you in any way, and then from, you know, just your own comfort care, you need to then educate yourself to understand risks of working in a cath lab with pregnancy, because it really is exceptionally small. Yeah, yeah, no, excellent points. I also was pregnant during my interventional fellowship here, so. I was going to say, I was, I've had two pregnancies and worked all the way through, it's, it's all fine. Yeah, yeah, thank you so much for those points. The biggest problem with working in the cath lab when you're pregnant is your belly moving. Exactly, it's a size factor, which is when the radiation risk is the lowest during your pregnancy, is, yes, correct. Yes, yes, I hit the mushrooms many times with my. Oh, yes, my baby moved the table all over the place. Yes, exactly, and then I only got to the point actually where I cathed from a stool. I lowered my belly on the stool, and I cathed with my hands above my head. Yeah, no CPR or the baby's gonna kick you. Yeah, I think my son had his co-cath numbers in utero, but yeah, no, excellent, excellent points. Doctors, Dr. Rabinovich, I wanted to sort of bring you into the discussion about teen care and also highlight your anesthesiology background, and it was mentioned in multiple discussions about the role of, you know, such an interdisciplinary approach to these patients, and I was hoping that you could give us a little bit, maybe put on your anesthesiology, anesthesia cap a little bit and provide some insight into the importance of that component of the team. Yeah, thank you for bringing this up. I think this is absolutely a terrific webinar, and I think everybody pretty much mentioned, and that is so true, the team approach, and two parts of the team that are absolutely your friends and you want to have around is an anesthesiologist, and you want to have an LND RN close by because they will get you out of trouble. Pregnant airway is not the same thing as a non-pregnant airway. It's swollen, the tongue is swollen, the uvula is swollen. It's not a melampotic class one. It's a class four, and if things go south, it can go south very quickly. The diaphragm is pushed cephalad, your FRC is decreased, you know, your oxygen consumption is up because you're working for two, and pregnant women will be saturated very quickly, so I think, and then mom won't like it and the baby won't like it. The, as I said, LND RN is controversial, and I think I would like to hear what the panel thinks, but fetal monitoring is actually not a bad idea, right? You know, uterus doesn't autoregulate, and the things that you do hemodynamically to the patient may clearly cause these cells, and it may not be a bad idea. It was mentioned, have a warm bed, have feeds there. Again, it's a team approach, and the more people who get there is helpful. I can say that no anesthesiologist will ever protest of being at standby because they get called too late. It's not great, and again, your physiology is not the same, right? You know, we all know this, you know, cardiac outputs to the roof, your ventilation to the roof, your pharmacology is not the same, right? You know, I'd make sure I check the ACT very, very assiduously because the heparin pharmacodynamics and pharmacokinetics are not the same in in perturians. So again, I think these are the two friends I would actually have in the lab at all times when you're dealing with a pregnant patient or perturian. Yeah, so Dr. Bordnick, I'll head back to you sort of again on the theme of the team discussion. For anybody who may be out there who is interested in starting a cardiocentrics team, you know, I know that it is not an easy path having done it at our institution, and it's very institutionally dependent. I don't know if you had any particular insights on how you started your program, and you know, I think you mentioned the sort of individual lens in your approach, understanding your environment and your patients, and how, you know, how you're able to do that there. Sure. So briefly, we were building a new outpatient tower, and there was a lot of concern that A, would patients come, and B, would we have enough patients to really justify this entire floor dedicated to cardiovascular medicine? And they were looking for new programs, and I had been talking to my MFM colleague because we were managing a patient with heart failure in our CCU, and we said, you know, we see women like this all the time, so what happens to them? You know, how do they get to cardiology, and how do we retain them in care? And so we just opened up. We just said, okay, we're going to start, and we just told, you know, everybody, okay, we're starting, and all of the referrals really come in through OB, so they would just send everybody, anybody they had any concern about, and we were all comers. So we see a lot of patients who have normal symptoms of pregnancy, maybe they have tachycardia, you know, that's like a third, but then there are two thirds that are divided between everything else, and it's a real spectrum. It's adult congenital heart disease, heart failure, EP issues, previous MIs, SCAD, you know, plethora. And so we didn't know, but now we're up to seeing, you know, 200 patients a year, and that's probably going to grow because we're not even capturing all of the preeclamptic patients. There's about 350 of those a year. So I think if you start it, you're going to find your population. I think the young women, particularly young women of color, disadvantaged women, immigrant women, non-English speaking women, they don't have a home in cardiology yet in most places. I think if you open your program and you just start, and you see your patients in combination with MFM, you're going to uncover that whole population. Yeah, grateful group of people you will ever find are obstetricians and maternal fetal medicine docs who have access to a cardiologist who's willing and able to help their patients. And the other thing that I wanted to emphasize, we didn't really touch on it tonight, but the importance of preconception counseling. A lot of these women, if we see them up front, it makes a huge difference in their outcomes. Yeah. No, a hundred percent. Yeah. That could be another, you know, 10 part series in itself. We now have family planning coming to our clinic and they're seeing our cardiology patients because they want to have a presence in the cardiology high-risk patients. Yeah. Yeah. It's interesting once you start a program, how it tends to evolve over time. You mentioned having, you know, scheduled monthly meetings. We also have the same setup. However, we've had a spat of very complex inpatient cases come up recently. So now we have a pop-off day per month in between our monthly scheduled meetings where we can use it for research discussions, but we can also use it for clinical case discussions in patients who, you know, really can't wait another three or four weeks, you know, to have another case review with the whole team. Maybe just as a last comment, I think you're a very good point. You need to collect your data. You need to put your outcomes, you know, out there and you need to talk about it and educate as many people as you can on both fields, but also the public because the women have to understand that they need to come in and that there's a place for them to go when they have symptoms because they often will ignore it. Remember that their postpartum visit is six weeks. The baby is two weeks. Right. Right. So we have a few minutes. I was going to ask Dr. Smillowitz, and this relates to some discussions you and I have had about and alluded to in terms of data collection and the importance of including more registries with pregnancy data and elements as well. You know, I don't know if you want to share some of the discussions and thoughts that we've had about the importance of that and sort of, you know, more systemic approaches to collecting data. You know, many of the discussions I've had with other interventionalists that say, well, I, you know, I only see a case or two of this maybe in my whole career. It's not that common, but in fact, you know, you showed your slides and your own data that the incidence is increasing and perhaps that's still an underestimate. We don't really know. So I'm happy to hear some of your comments on that. Yeah, I think that's a great, it's a great point. So, you know, part of the challenge of something that's rare, but devastating is that a provider may not see this every year, you know, maybe once a year, maybe less than once a year. And so we're really never going to get the center experience to really manage these cases well without combining data. And so that's why creating national registries at multiple hospitals and multiple facilities that can pool the knowledge and the experience that they've had so that we can guide treatment for everybody going forward. And so, Dr. Park, we've discussed about, you know, potentially even having the large ongoing national registries through the ACC collect data on pregnancy, because this is really something that's just not collected. And so it's being missed in all of the MI registries ongoing currently. So it's a huge area of unmet need. And I think it's really ripe for investigation because it's uncommon, but not so rare that we can't get large numbers of patients if we pool our data. Yeah. And especially as maternal age is advancing, that really, you know, the numbers are just going to unfortunately continue to increase. Whether we want to or not, we're all going to see at some point. And as the risk factor modification gets worse in our country, right? I mean, with rising rates of diabetes and obesity, you know, that's going to drive the risk of ischemic complications in pregnancy. So we're going to see it more. Absolutely. So we've gone a couple minutes over, but thank you everyone for still sticking around. And I want to really, you know, give a huge thanks to our panelists and our speakers for really engaging discussions. And all of our participants. So thank you all so much for your participation. Have a good evening.

cardio obstetrics teams

pregnant women with heart conditions

maternal care

interdisciplinary collaboration

national registries